BRITISH MEDICAL JOURNAL VOLUME 294 25 APRIL 1987 1101 Br Med J (Clin Res Ed): first published as 10.1136/bmj.294.6579.1101-d on 25 April 1987. Downloaded from comment on the effects ofstanozolol on liver function psoriasiform eruption worsened. Treatment was thus Drug points in patients with pre-existing liver function abnormali- stopped again, and two months later the eruption had ties. Chronic abnormalities of liver function often cleared without any topical treatment. Cardiac side effects of pentamidine occur in haemophiliacs as a result of the use of The develo'pment of these psoriasiform eruptions blood products.' Though this is usually subclinical, after treatment with penicillamine and their improve- Dr B J BOUGHTON (Queen Elizabeth Hospital, Edg- these patients have chronically raised serum amino- ment after the treatment was stopped strongly suggest baston, Birmingham B15 2TH) writes: Pneumocystis transferase activities. We have studied the effect of a causal relation. In the second patient the abrupt carini1 pneumomtis is a well recognised complication stanozolol on the coagulatiornand fibrinolytic systems cessation oftreatment with the systemic steroid was a in patients who are immunosuppressed because of the in haemophiliacs with such abnormalities of liver possible cause of the onset of psoriasis, but the acquired immune deficiency syndrome (AIDS) or function, including several with a history of viral eruption deteriorated when penicillamine was later cancer chemotherapy. Co-trimoxazole is used widely hepatitis.2 Though we showed no beneficial effects reintroduced, the dose of prednisolone remaining to treat this condition, but up to 35% ofpatients do not on the coagulation system, we noted a pronounced unchanged. Neither patient had a personal or family respond, and in these patients pentamidine may be the improvement in liver function during the study. Ten history of psoriasis. An exacerbation of pre-existing only effective drug.' In contrast to co-trimoxazole, patients with severe haemophilia were studied. Each psoriasis after treatment with penicillamine and pentamidine has serious side effects, including renal received 10 mg stanozolol a day for 28 days. A recurrence on subsequent rechallenge with the drug impairment, pancreatic islet cell toxicity, and severe significant reduction in alkaline phosphatase and has been reported.' Two other cases of psoriasis hypotension.2 We used pentamidine to treat a patient serum alanine aminotransferase activities occurred after treatment with penicillamine are known to with pneumonitis resistant to co-trimoxazole, and our within a week of starting treatment, and this was the manufacturer, and five cases, including one observations help to explain its hypotensive effects. A maintained throughout the study. When treatment exacerbation of pre-existing psoriasis, have been 22 year old man underwent remission induction with stanozolol was stopped activities of both alkaline reported to the Committee on Safety ofMedicines. treatment for acute lymphoblastic leukaemia and phosphatase and alanine aminotransferase returned to entered remission. After five months of oral main- pretreatment levels within seven days. Other studies 1 Daunt SON, Cawley MID, Robertson JC, Cox NL. A placebo tenance chemotherapy he developed a dry cough and have also shown stanozolol to have beneficial effects controlled trial ofo-penicdillamine in psoriatic arthritis: interim shortness of breath. Blood pressure on admission was on liver function. Improvement in serum bilirubin report ofbenefit. BritishJounl ofRheumatol 1986;25:74. 120/70 mmHg and the pulse rate 60 beats/mmin. concentration in a patient with Gilbert's disease has Arterial Pao2 was 6-7 kPa, and chest radiography been reported,3 and a controlled study of treatment showed evidence of widespread interstitial pneu- with stanozolol in children with hepatitis showed a Hypertension in association with buserelin monitis. P carinni was not detected in sputum, but more rapid return to normal serum transaminase antibody titres for P carinmi rose over the next three activity (Sterling Research Laboratories, on file). The the effect Drs J F R BARREr and M E DALTON (Department of weeks from < 1/16 to 1/64. Five days oftreatment with mechanism of these changes is unclear, but Obstetrics and Gynaecology, St James's University intravenous co-trimoxazole (640 mg trimethoprin, seems somewhat paradoxical in view of the report by Hospital, Leeds LS9 7TF) write: We describe here a 3200 mg sulphamethoxazole) was ineffective, and Dr Evely and others. The clinical importance of to case of hypertension occurring in a patient treated treatment with pentamidine mesylate 240 mg daily these improvements in liver function remains with the gonadotrophin releasing hormone agonist was started. Because of thrombocytopenia this was be established, but stanozolol may be beneficial in with buserelin. Neither the manufacturer nor the Com- given intravenously as an eight hour infusion. The patients chronic liver disease. mittee on Safety ofMedicines knows ofany other cases on the and over patient's fever subsided second day, 1 Forbes CD. Clinical aspects ofhaemophilias and their treatment. ofthis association. the next two weeks his respiratory symptoms resolved In: RatnoffOD, Forbes CD, eds. Disordersofhaoemostasis. New The patient was a 39 year old unmarried woman and radiography showed that the pneumonitis had York: Grune and Stratton, 1984:177-239. (nulliparous) being treated for endometriosis. Initial cleared. On the sixth day of treatment with pentami- 2 Greer IA, Greaves M, Madhok R, ct al. Effect of stanozolol on therapy with danazol and dydrogesterone was ineffec- dine he could not sit upright or stand without factors VIII and IX and serns aminotransferases in haemo- tive and accompanied by intolerable side effects. faintness, and his blood pressure was 70/50 mmHg philia. Thromb Haanost 1985;53:386-9. There was no personal or family history of hyper- supine and 60/0 mmHg erect. This was associated 3 Preston FE, Burakowski BK, Porters NR, Malia RG. The tension or renal disease. Her blood pressure during with a sinus bradycardia (40 which did not fibrinolytic response to stanozolol in normal subjects. Thromb beats/min), Res 1981;22:543-51. and after her hospital admission, when the condition vary with posture. Tests of cardiac autonomic func- was diagnosed by laparoscopy, was normal. She did tion showed 0% variation in the pulse rate during not smoke. Buserelin (Suprefact) 900 pg/day was respiration (normal >10%) and only 7% variation administered by two intranasal puffs, each delivering during a Valsalvamanoeuvre (normal >10%). Electro- Psoriasiform eruptions associated with a metered dose of 150 pg/puff, three times a day for cardiography showed no evidence of intracardiac penicillamine three months. Amenorrhoea was achieved and she was conduction defects, and the short tetracosactrin test pain free, but her blood pressure at the clinic was yielded normal results. His blood pressure did not 160/120 mm Hg. Measurements were repeated at half respond to intravenous colloids, graded compression Drs JOHN C FORGIE and ALLAN S -HIGHET (York Y03 write: A 60 year hour intervals with the patient lying supine for two stockings, or fludrocortisone, but the bradycardia and District Hospital, York 7HE) hours and were unchanged over this period. The woman with a 35 of http://www.bmj.com/ hypotension resolved within four days of stopping old year history seropositive buserelin was stopped and other possible causes treatment with pentamidine. Hypotension did not rheumatoid arthritis complicated by Felty's syndrome for the hypertension investigated. All investigations, recur during four subsequent courses of leukaemia developed a psoriasiform eruption seven months after The including blood electrolytes, urinary vanillylmandelic chemotherapy withvincristine. Pentamidineprobably the introduction of treatment with pencillamine. acid excretion, creatinine clearance, chest radiograph, induces hypoglycaemia because of its biguanide like initial dose was 125 mg daily, which was gradually Six weeks after the higher and a renal diethylene triamine penta-acetic acid scan structure, but the hypotensive side effects are poorly increased to 500 mg daily. were normal. Her blood pressure gradually fell over documented. Only three similar episodes have been dose had been introduced the eruption appeared. A well developed on the left shin, the following four weeks to 130/80 mm Hg, but over notified to the Committee on Safety ofMedicines, and defined scaly plaque the next six months it once again rose and seemed to be one case of a reaction after rapid intravenous infusion with scaling of the soles of the feet. Typical psoriatic permanently raised. of the drug has been reported.3 The present evidence nail changes developed, including pitting and

strongly suggests, however, that hypotension induced onycholysis. Finally, discrete, small, scaly eruptions on 25 September 2021 by guest. Protected copyright. by pentamidine is caused by autonomic neuropathy appeared on the arms. Treatment with penicilamine and sinoatrial node dysfunction. Pentamidine will was stopped and the eruption settled with topical probably be used increasingly to treat P carinii clobetasone butyrate ointment (Eumovate). There infections in patients with AIDS, and if it is admini- was still some scaling of the soles of the feet, which Correction stered intravenously patients should be monitored for slowly improved with the application of beta- cardiac side effects. methasone dipropionate 0-05% and salicylic acid 3% (Diprosalic). Dangers in treating hyponatraemia Her other medications at the time ofonset included 1 Haverkos HW. Assessment of therapy for Pneumocystis carinii triazolam, naproxen, frusemide, spironolactone, and We regret that the table from this letter by Mr A N pneumonia. AmJ Med 1984;76:501-8. Ghanem and others (28 March, p 837) was accidentally 2 Tester-Dalderup CBM. Antiprotozoal drugs. In: Dukes H, ed. prednisolone (12-5 mg daily), but she had taken these omitted. Meyler's side effects of drugs. 10th ed. Amsterdarm: Elsevier, for several years, and they were continued while the 1984:536. eruption settled. Biochemical abnormalities of the transurethral reaction 3 Stark R, Crust F, Clemmner T, Ramirez R. Fatal Herxheimer A 58 year old woman with a two year history syndrome in case I reaction after pentamidinein pneumocystis pneumonia. Lancet of seropositive rheumatoid arthritis developed 1976;i: 1 193-4. of well End of Day after operation a psoriasiform eruption red, scaly, itchy, Before operation Day demarcated plaques on the hands six weeks after Normal operation (1050)* 1030t 1130t 1300 1700 2 starting treatment with penicillamine 125 mg daily. Serum sodium She had been taking 9 mg prednisolone daily for (mmoVI) 135-145 144 107 109 122 126 138 145 Severe cholestasis associated with stanozolol over a year but had stopped taking it by mistake Potassium (mmaol/) 3-5-5-1 3-0 6-1 5-7 59 4-9 4-4 4 when treatment with penicillamine was started. Urea (mmol/l) 2 5-6-5 9-5 12-2 19-9 20-2 20 19-7 14-1 Dr D A GREER (University of Edinburgh, Edinburgh Prednisolone was subsequently restarted (5mg daily). Oumolality (mmoUl/) 275-295 249 251 273 280 302 304 EH3 9EsW) and colleagues write: Dr R S Evely and She had been taking ketoprofen 200mg daily for two Albumin(g/l) 30-50 34 20 26 26 26 colleagues (7 March, p612) reported severe cholestasis months before the onset ofthe eruption and continued Vasopressin (ADH)(pg/ml) 4-6 5-5 2-2 9-4 associated with stanozolol in patients with no history to do so. Treatment with penicillamine was stopped Ammonia of liver disease. As stanozolol is C17 substituted one month after the onset of the eruption, which was (punolll) <76 03 126 62 52 testosterone such a complication is to be expected. resolving when she was seen 10 days later. Treatment Glycine (pmoVIl) <422 6741 5072 4900 2072 though it is fairly rare. The authors, however, did not with peniciLlamine was then restarted and the *Femsemide 80 mg x 2. t500 ml of 5% sodium chiloride given in one hour.